NEJM realized the PQRS Emperor has no clothes.
Perhaps the only health policy issue on which Republicans and Democrats agree is the need to move from volume-based to value-based payment for health care providers. Rather than paying for activity, the aspirational goal is to pay for outcomes that take into account quality and costs. In keeping with this notion of paying for value rather than volume, the Affordable Care Act ACA created the “value-based payment modifier,” or “value modifier,” a pay-for-performance approach for physicians who actively participate in Medicare. By 2017, physicians will be rewarded or penalized on the basis of the relative calculated value of the care they provide to Medicare beneficiaries.
Although we agree that value-based payment is appropriate as a concept, the practical reality is that the Centers for Medicare and Medicaid Services CMS, despite heroic efforts, cannot accurately measure any physician’s overall value, now or in the foreseeable future. Instead of helping to establish a central role for performance measurement in holding providers more accountable for the care they provide and in informing quality- and safety-improvement projects, this policy overreach could undermine the quest for higher-value health care. Yet the medical profession has been remarkably quiet as this flawed approach proceeds.
How many tens of thousands of hours are spent jumping through hoops like these that turn out to be more meaningless (or worse) ‘government work’?
All the articles about cancelled Individual Insurance plans have some variation of this spin in them:
For some who have received the letters, the new plans being offered are more expensive, but for others — especially those who qualify for a federal subsidy to bring down the cost of the premium — their insurance bill will go down.
Here’s the thing: people (like me) in the Individual market don’t have IBM or Exxon sitting across the table from an insurance company, dealing from a position of some strength. We’re individuals. We’re independent Contractors (me), self employed and scraping by, or doing well. We looked at our options, bought plans we could afford, and realized there are tradeoffs from a cost/benefits standpoint. Not a lot of people in that group bought a soup-to-nuts expensive plan (some did, most don’t).
The emphasized thing above is pure spin on the part of the writers. I have no doubt they’ve been told this over and over, but I have yet to see one article about someone in the Indy market that got a ‘better’ plan that dropped in price. There will be a few, but most if not all will see their costs go up.
Just so you see it for what it is.
A constitutional argument. From docs:
The Association of American Physicians & Surgeons (AAPS) has filed a lawsuit today in federal court to halt the unlawful revisions to ObamaCare (the Patient Protection and Affordable Care Act).
The separation of powers required by the Constitution prohibits the executive branch—the Obama Administration—from rewriting laws passed by Congress. Yet that is what Obama has done by changing key parts of ObamaCare in order to implement it.
The AAPS lawsuit, which was filed today in the Eastern District of Wisconsin, asks the Court to enjoin the Obama Administration from imposing its “individual mandate” while delaying the “employer mandate.” The law that was passed by Congress in 2010 requires that the employer mandate go into effect at the same time as the individual mandate: Jan 1, 2014.
“The U.S. Constitution requires a strict separation of powers between the three branches of government, such that the executive branch cannot change laws passed by Congress,” AAPS’s lawsuit explains. By imposing the individual mandate in 2014 without the protection of the employer mandate, the Obama Administration has changed the legislation passed by Congress.
Bizarre congress is super-cool with the executive branch picking and choosing the laws to bother enforcing.
I’m not usually up this early. Ate a lot of carbs last evening, paying the price all night. And today. Probably tomorrow, from the course of events.
Enough about me. This is a nice summary of thoughts on Obamacare:
…What do we have to look forward to? Obamacare in effect outlaws traditional insurance and substitutes in its place a mandatory system of prepaid health care administered by the kind and gentle souls who run insurance companies, which is in fact in many ways similar to the mandatory health-savings accounts in Singapore — minus the property rights, wealth building, heritability, efficiency, and consumer choice. Likewise, Obamacare is in some ways similar to the Swiss system, but without the downward price pressure associated with high out-of-pocket expenses, and, as we have seen in recent weeks, also minus the competence and efficiency. As they say in Switzerland: Ich be chrank.
And it is worth remembering that under Obamacare there will still be millions of Americans with no health-insurance coverage, while many (and possibly most) of those added to the coverage rolls will simply be given Medicaid cards,…
Speechless, I am.
The top part of the article is typical Klein (intent is all that mattered, not execution, which he only allows to one party), but his writing about government in general and government IT in particular is interesting:
The saga of healthcare.gov has been a symphony of government inefficiency. The effort, directly overseen by the IT department of the Centers for Medicare and Medicaid Services, involved no fewer than 55 contractors. The process was thick with lawyers and political interference. In violation of current best practices in the software world, the code was kept almost entirely secret; other engineers weren’t able to point out its flaws, and it wasn’t tested rigorously enough. The Obama administration has been assailed for not calling in Silicon Valley’s top minds to collaborate, but that misses the fundamental problem: The best coders in the Valley would’ve never agreed to work under such deadening, unpleasant conditions.
There are people in Washington who share Bracken’s views, but their struggle against bureaucratic inertia can seem Sisyphean. “Government becomes really afraid of failure, which is a bit ironic, as this ends up leading to failure,” says Clay Johnson, a technologist who was one of the White House’s presidential innovation fellows. “But that fear of failure leads them to only want to work with known quantities, and known quantities mean contractors who’ve done this work in the past. That puts them with a group of entrenched vendors who haven’t really had to compete in the world of technology.”
That fear of failure has been institutionalized in the way the federal government awards contracts. The complex, arcane process favors those companies that devote resources to mastering it and repels the Silicon Valley startups the government desperately needs. “I realized I could figure out how to develop these very complex, very new software programs, or I could figure out how to contract with the government,” says Trotter, who worked on health IT projects with the Veterans Administration. “And so I chose to do the thing that was innovative.”
The front end of the website will eventually get fixed, then the back end. Then we’re going to wait for the employer mandate to hit. All this market disruption was just the self-insured, a very small piece of the health insurance pie.
Wait, wait, this was supposed to bend the cost curve Down…
It is also ironic that high-deductible, catastrophic plans are precisely what young people should be buying in the first place. They are inexpensive because they provide coverage for unlikely, but expensive, events. Routine care is best paid for out-of-pocket by value conscious consumers. But Obamacare outlaws these plans, in favor of what amounts to prepaid medical treatment that shifts the cost of services to taxpayers. In such a system, patients have no incentive to contain costs. Since the biggest factor driving health care costs higher in the first place has been the over use of insurance that results from government-provided tax incentives, and the lack of cost accountability that results from a third-party payer system, Obamacare will bend the cost curve even higher. The fact that Obamacare does nothing to rein in costs while providing an open-ended insurance subsidy may be good news for hospitals and insurance companies, but it’s bad news for taxpayers, on whom this increased burden will ultimately fall.
Lack of skin in the game.
Remember this? (From this blog):
Heroic State Attorneys General band together to force lawful commerce to stop, because they don’t like it.
July 13, 2013 by GruntDoc
So, 22 State Attorneys General sent a letter to Urban Outfitters demanding they stop selling gag merchandise described as their ‘Prescription line’, which includes the terrifically dangerous items of
glasses, coasters, mugs, drink holders and related products that mimic prescription pill bottles and prescription pads.
Want to guess what I found at The Onion’s online store?
The mug that causes death by prescription drug OD’s.
I knew I liked The Onion.
Read and weep. My comments in [brackets]:
…[interviews with medical insurance policy-type reps in Washington]
One key worry is based on the fact that what they’re facing is not a situation where it is impossible to buy coverage but one where it is possible but very difficult to buy coverage. That’s much worse from their point of view, because it means that only highly motivated consumers are getting coverage. People who are highly motivated to get coverage in a community-rated insurance system are very likely to be in bad health. The healthy young man who sees an ad for his state exchange during a baseball game and loads up the site to get coverage—the dream consumer so essential to the design of the exchange system—will not keep trying 25 times over a week if the site is not working . The person with high health costs and no insurance will . The exchange system is designed to enable that sick person to get coverage, of course, but it can only do that if the healthy person does too . The insurers don’t yet have a clear overall sense of the risk profile of the people who are signing up, but the circumstantial evidence they have is very distressing to them . The danger of a rapid adverse selection spiral is much more serious than they believed possible this summer . They would love it if the administration could shut down the exchange system, at least the federal one, until the interface problems can be addressed. But they know this is impossible .
A terrifically scary article (read it all ™), but this paragraph has so much implied information in it it jumped out as needing some amplification.
1: Why would he? He’s actuarially bulletproof, and has as much need of medical insurance as he does a 401k (unemployment joke), but seriously: this youngster is the basis for paying the ACA bills. If the young and healthy and unlikely to need medical insurance don’t sign up the ACA insurance house of cards collapses (see next):
2: Why wouldn’t they? This is the group the ACA is aimed at, those who can’t get insurance at all, or who have it (Cobra, etc), but for this group insurance is prohibitively expensive. Were I in their shoes I’d be hitting this site 18 hours a day and not quitting until I got insurance and a subsidy. Hint, this group is very to horrifically expensive, and require their costs to be spread far and wide for insurance to work.
3: To belabor the point, insurance companies don’t print money to pay bills, they transfer money from the payments of those paying for insurance who don’t wind up using it to the bills of those who do. Therefore not enough insured paying (but not using) the insurance company runs out of money, then the insured aren’t insured when the company goes broke. That’s ungood.
4: Insurance companies understand medical cost risk like no other group, and were this good news for them (non-distressing news) they’d be singing this to the heavens/news, as a way to sign up the  group. Then it’d be ‘cool!’, which would cascade into more young/well signups.
5: This is inexplicable. Insurance companies abhor risk, this was a completely foreseeable risk in an unknown situation, unless there were some significant assurances from On High that Nothing Can Go Wrong. Which they would be dumb to just swallow whole. This part of the mechanism of bargaining still bugs me, as I don’t have an explanation for why an entire, smart and profitable industry would buy into a scheme that could destroy it quickly and painlessly. Remember this, they walked into the ACA eyes wide open.
6. It’s hard to stop a process bought into under a combination of duress and greed, either objection draws credibility into question.
No secret, I’m totally against (and aghast at) the ACA. That said, it’s more than curious a nation that put men on the moon with slide rules cannot make an insurance marketplace with roughly a half a billion dollars and a three year head start.
A concise treatise on the problems with TPa. Well Done!
Facebook Like Now Covered by the First Amendment – Applications for Healthcare | Hospital EMR and EHR
This is at the end of an article talking about something else, but it deserves it own highlight:
My favorite thing is when healthcare organizations try and control and restrict social media. As many institutions have learned, that’s impossible to do. Instead, it’s much more effective to educate and inform people on their use of social media. The best reason you should educate and inform as opposed to control and restrict is the message it sends to your employees. The former sends a message of trust and respect while the later does the opposite.
U.S. pilot scares off Iranians with ‘Top Gun’-worthy stunt: ‘You really ought to go home’ – Washington Times
In what only can be described as a scene out of Tom Cruise’s “Top Gun,” Gen. Mark A. Welsh III, Air Force chief of staff, describes how F-22 stealth jets scared off Iranian jets from a U.S. drone flying in international airspace.
Click through to see what happened. I’ll be the in-cockpit tape of that gets out someday…and it will be cool.
Two other thoughts: are we now riding shotgun on drones (aren’t the drones so we don’t have to endanger pilots), and/or, was this bait to see what Iranian air intercept does?
Our Government is out of money. That’s given. Related but unrelated, our Government=Things we do together.
The Army Corps of Engineers recently decided that plowing Govt. Park access fees back into the parks through non-profits is verboten, because, get this, the money isn’t going into the US Treasury.
No thought to what makes the parks work. No thought to what the NonProfits (that’s Washington for sucker-bait) put into the parks, or what the Federal version of park running and maintenance will cost (that’ll be way way more than non-profits did it for). Or the park non-profit employees who are now out of a job.
This smacks of bureaucracy run amok, remote pencil pushers running roughshod over local policies that actually serve the constituents, i.e., normal people who like parks.
I’ll call my Congressperson tomorrow. Perhaps sense will prevail, but I have doubts.
Now, about that Government takeover of healthcare, still think that’s a terrific idea?
Wait for it….
Owner isn’t blaming dog for accidental shooting, Police say
By Deanna Boyddboyd@star-telegram.com
FORT WORTH — Surprisingly, this canine isn’t in the doghouse.
A 78-year-old woman was shot in the foot late Saturday when her shotgun discharged after her dog accidentally knocked it over, police reported….
You have to click through to read the best Police quip of the year. [Read more...]
The Defikopter is a UAV that can be activated by a smartphone app to automatically take to the skies and drop a defibrillator to medical personnel on the ground, shaving precious seconds from the time it takes to receive treatment for cardiac arrest.
The idea for the drone comes from Definetz, a non-profit group dedicated to preventing deaths due to heart failure.
Interesting idea. Won’t work here in the Land o’ the Lawsuit.